Neal Howard: Hello and welcome to Health Professional Radio. I’m your host Neal Howard, thank you for joining us here on this Health Supplier Segment of the show. Our guest today is returning guest Dr. Henry Boucher, orthopedic surgeon at MedStar Union Memorial Hospital in Baltimore, Maryland. Specializing in primary revision and partial knee replacements as well as primary and revision hip replacement and hip resurfacing. Dr. Boucher was named ‘2016’s Top Doc’ by Baltimore Magazine for Orthopedic Surgery in Joint Replacement, a great honor. Welcome back to Health Professional Radio doctor.

Dr. Henry Boucher: Thanks for having me Neal.

N: Thanks. I understand that there’s some exciting things happening in the world of knee replacement. As far as total knee replacement, is that something that’s common or has the procedure that you’re going to talk about made it more mainstream?

B: Total knee replacement is an extremely common procedure nowadays. It’s even much more common in partial knee replacement and total knee replacement is more common than hip replacement. As a rough estimate, there’s probably 800,000 to a million of these procedures done in this country alone per year.

N: So among those, how many of them have a very positive recovery rate and as far as the recovery, and therapy, physical therapy, and the prevention, or the foresight to see problems ahead?

B: Well I think that’s a great question and something that the knee replacement doctors kind of struggle with. So it depends on who you ask that question to. If you ask the doctors about their results and what they see objectively, they’re going to say that better than 90% of their patients do great and objectively, they may look great, they may have recovered well, have a good looking incision, have good range of motion, have good function. However, if we ask the patients, that number dips. So we’re talking in the 80 something percent range that patients are very satisfied with their knee replacement. So there’s a significant percentage that have left over complaints and that a very small percentage that really unhappy with their outcome. And so that’s what we are trying to improve on and I think that’s where technology is headed in knee replacement.

N: What about the different nuances of a knee replacement procedure? Does every doctor, some doctors have knowledge of a certain approach, or a certain cut, or a certain instrument, while others don’t yet have that knowledge. Is this new technology in robotic knee replacement, talk about that a bit and talk about getting the word out there about it.

B: Sure. So naturally, there’s different skill sets for each surgeon. And people forget that a knee replacement surgery is really more of a soft tissue procedure. The carpentry is important but hand doing the soft tissues, the ligaments, that’s a very important to have so a knee can feel and function. And naturally, surgeons can handle that differently and we try to standardize that and I think surgeons become better the more they do so typically, the higher volume surgeons have better outcomes than the lower volume even though some of the lower volume surgeons can be excellent surgeons and do a good job. So where robotics come in and sort of computer navigated surgery which is really been around for at least 10-15 years and that’s where sort of we started with knee replacement, is a computer navigation would try and help us get the angles and the construction work done very accurately and give us some information on what the soft tissues are doing. Where the robotics takes us as the next step because not only can it sort of give us real time information, is that the robotic arm assist us during the procedure, to make sure that we’re accurate but we can also more accurately preoperatively plan the surgery because the patient gets a CT-scan, so we already know the size of the implant, we know where the cut should be, and then the robotic arm, make sure we do it accurately. So even the best surgeons, their accuracy has a limitation to them and we already know that computer navigated surgery and robotic surgery will show the same thing, is that that accuracy is much improved.

N: What percentage of control is human and the other programming?

B: So if we take the example of doing a robotic knee replacement, so the surgeon and the technician that helps run the computer program, they set the plan up. So the surgeon okays the plan, they do the sizing, they tell what position they want, what particular angle they might want. And then the surgeon has to register the anatomy to match it up with the CT-scan, that all gets put into the computer which goes thru algorithms that I don’t understand (laughs). And then basically when the robotic arm is engaged and extract real time by an infrared camera, the surgeon runs the arm so the surgeon pulls the trigger, it starts the saw, but you can’t make the arm go outside of the plan and it’s a volumetric plan so once the saw violates the border, it shuts off. So for instance we were training in the lab with some of my colleagues and one of the things we worry about is cutting one of the ligaments in the back of the knee. So we had the plan done and so for some of my partners who’ve never seen the technology, I’d say “Try, try and cut it.” They try and force that saw to go cut that ligament, it can’t be done. So hence, there is I think an added level of safety.

N: Yes. So even if a surgeon, unfortunately, makes a slip the program will compensate and say, ‘Hey, this is as far as we are supposed to go, I’m not sure what you’re doing but this is what I’m going to do.’ Great.

B: Alright. The robotic arm will lock you out and these things are incredibly strong, there’s no way a human can overpower s robotic arm. When it’s stops, it stops (laughs).

N: When it comes to training, how user friendly is this? I mean if you’re a surgeon who’s unfamiliar with robotics, are you talking about a five year training program or is this something that with proper support, it’s pretty easy to gain some skills?

B: I think it’s pretty easy to gain some skills. I think it’s easy to understand what you’re trying to do with the plan. I think the robotic surgeon can make it even a lot easier because you don’t need the traditional jigs which have to be set up and positioned in certain ways. And the tech hands it to you, it could be on the wrong angle or on the wrong number and nobody notices and now you’ve made a cut that you didn’t like, that get sort of eliminated because as long as you’ve entered the plan properly, you shouldn’t have those issues. So there is a learning curve because you have to learn how to attach the trackers to the leg, you have to learn how to register anatomy which is basically like playing a video game, you have to pick points to register the anatomy before you sort of engage to robot to do the surgery. So the reason learning curve, but I don’t think it’s steep. It doesn’t really change how you make the incision or the exposure, so that’s not difficult, it’s just getting used to, “I’m not going to use the traditional jigs and guides for this, I’m going to trust that the robot is going to replicate the plan that we had set up.”

N: Now, there are obvious benefits for the physician as far as performing the surgery and recovery benefits for the patient. But what about educating the patient on the procedure, convincing them of the benefits, the advanced recovery time, as well as the cost effective aspects of this surgery? Sometimes you would like to not to do something because of the cost or the lack of coverage?

B: Right. Well in general, using any navigated surgery or robotic surgery will increase the cost somewhat because they have to an added scan. So the patient has to do a CT-scan which traditionally is not necessary for a traditional knee or hip replacement, so that’s an added cost. You’re trying to make that up on the back-end though because if you can eliminate failures from now position, or instability, or patient complaints because of sizing issues of the implant – that cost a lot of money to correct when you have to do with revision surgery. So it’s kind of harder to find how much extra it really is, so the technology in the end could end up saving money if it reduces revision rates due to failures. So that data is pretty tough to track and to talk to patients about it, patients understand. If you tell patients, we do a good job with the surgery in general. But the reason we use it is to try and improve accuracy and theoretically accuracy should improve outcome and in a surgery where there is still 15-20% of the patients have some leftover complaints. Hopefully, we get that number to decrease. It’s not a very hard sell to patients because they don’t want to be experimented on. So getting your first patient to sign up when you’ve not used it before, if you’re not familiar with it, you have to have somebody who really believes in the technology to go forward. But I personally don’t think it’s dangerous because in reality your backup is, if you don’t like how it’s going, you open the standard instruments and you do it the old-fashioned way.

N: There you go, absolutely. Now where can our listeners go and get more information about MAKO Robotic Total Knee Replacement at MedStar Union Memorial Hospital?

B: So they can go to MedStar’s website or they can even go on the web and look up the MAKO which is the brand of the robotic arm and they will have no trouble finding information for that.

N: Thank you. It’s been a pleasure talking with you today doctor.

B: Thank you Neal.

N: Thank you. You’ve been listening to Health Professional Radio, I’m your host Neal Howard with Dr. Henry Boucher, member of the American Association of Hip and Knee Surgeons and a fellow of the American Academy of Orthopedic Surgeons. We’ve been talking about MAKO Robotic Total Knee Replacement. Transcripts and audio of this program are available at healthprofessionalradio.com.au and also at hpr.fm, and you can subscribe to this podcast on iTunes.